Formulário de Autorizacao de Viagem

[Pages:1]REP?BLICA FEDERATIVA DO BRASIL MINIST?RIO DAS RELA??ES EXTERIORES

Consulado-Geral do Brasil em Atlanta 3500 Lenox RD NE - Atlanta, GA 30326 Tel: +1 (404)949-2400 - FAX: +1 (404) 949-2402 website e-mail passaporte.atlanta@.br

AUTORIZA??O P/ CONCESS?O DE PASSAPORTE P/ MENOR COM ANOTAC?O DE AUTORIZAC?O DE VIAGEM

PREENCHER EM LETRA DE FORMA, SEM RASURAS E SEM ABREVIA??O

AUTHORIZATION TO ISSUE BRAZILIAN PASSPORT TO MINOR WITH TRAVEL AUTHORIZATION

FILL OUT IN ALL CAPITAL LETTERS WITHOUT ERASURES OR ABBREVIATIONS

Pelo presente, autorizo(amos) o Consulado-GeraI do Brasil em Atlanta a emitir documento de viagem para nosso(a) filho(a) menor, identificado(a) a seguir. I (We) hereby authorize the Consulate General of Brazil in Atlanta to issue a travel document to my (our) child, hereunder identified.

Nome completo do menor / Minor's full name:

Data de Nascim.: Date of Birthdia / day m?s / month ano / year

Sexo/Gender:

Masculino Male

Feminino Female

Cidade de Nascimento / UF City of Birth / State

Pa?s de Nascimento Country of Birth

SELECIONE A(S) OP??O(?ES) ABAIXO DESEJADA(S) / SELECT ONE OR MORE OPTIONS BELOW: Autoriza??o para CONCESS?O DE PASSAPORTE PARA MENOR COM ANOTAC?O DE AUTORIZAC?O DE VIAGEM. Na oportunidade, tamb?m autorizo(amos), nosso(a) filho(a) menor, aqui identificado(a), a viajar: / Authorization to ISSUE BRAZILIAN PASSPORT TO MINOR WITH TRAVEL AUTHORIZATION. I (We) also authorize, my (our) minor child, here identified, to travel:

desacompanhado; / Unaccompanied ; ou / or

acompanhado com apenas um dos respons?veis, indistintamente; / Accompanied by either one of the parents; e/ou / and/or

acompanhado por terceiro / accompanied by a third person,___________________________________________________________________________________________

(nome completo / full name), _______________________________________ (n? Passaporte / # Passport).

SELECIONE A OP??O ABAIXO DESEJADA / SELECT ONE OPTIONS BELOW: Autorizo(amos) a inclus?o de autoriza??o de viagem / I(We) authorize the inclusion of a travel authorization:

v?lida pelo prazo do passaporte / valid for the same period of the passport; ou / or

v?lida at? _____/_____/________ (dia/m?s/ano) / valid until _____(day/month/year).

* * * ATEN??O: ENVIAR OS DOCUMENTOS ORIGINAIS UTILIZADOS NO PREENCHIMENTO DESTE FORMUL?RIO. (PAIS BRASILEIROS DEVEM ENVIAR DOCUMENTOS BRASILEIROS) * * * ATTENTION: SEND THE ORIGINAL DOCUMENTS USED IN COMPLETING THIS FORM. (BRAZILIAN PARENTS MUST SEND BRAZILIAN DOCUMENTS)

Nome completo do PAI/Resp. -- FATHER's full name:

Nome completo da M?E/Resp. - MOTHER's full name:

Nr. Passaporte/RG - Passport/ID #:

Data de Expedi??o - Date of Issue: ?rg?o expedidor - Issued by:

dia / day

Assinatura do Pai/Resp - Father's Signature

m?s / month

ano / year

Nr. Passaporte/RG - Passport/lD #:

Data de Expedi??o - Date of Issue: ?rg?o expedidor - Issued by:

dia / day

Assinatura da m?e/Resp - Mother's Signature

m?s / month

ano / year

Notary: Please validate signature bellow, using one stamp per signature.

On ____/____/_____, before me, the undersigned, a notary public for the On ____/____/_____, before me, the undersigned, a notary public for the

State of_____________, County of______________ personally appeared State of______________, County of______________ personally appeared

(full name):___________________________________________________ (full name):___________________________________________________

who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, execute the instrument. I certify, under PENALTY OF PERJURY under the laws of the State of __________ that the foregoing paragraph is true and correct. Witness my Hand and Official Seal.

who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, execute the instrument. I certify, under PENALTY OF PERJURY under the laws of the State of __________ that the foregoing paragraph is true and correct. Witness my Hand and Official Seal.

SIGNATURE AND STAMP OF NOTARY PUBLIC

SIGNATURE AND STAMP OF NOTARY PUBLIC

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